Urinary retention is one of the most prevalent urological complaints resulting in patients presenting to the emergency department. It is the inability to pass urine and can be acute or chronic. Typically, diagnosis is via a high post-void residual; post-void residual measurement is by using a bladder scanner or ultrasound to estimate the amount of urine remaining in the bladder after urinating. Urinary retention presents much more commonly in men than in women due to benign prostatic hyperplasia. Two of the most common causes in women of chronic urinary retention are bladder muscle dysfunction and obstruction.
Common causes of urinary retention, both acute and chronic, include but are not limited to medications, nerve injury during surgery, cystotomy during surgery, obstruction (vaginal hematoma, vaginal packing, sling, urethral foreign body, pelvic organ prolapse, urethral injury, constipation, failure of pelvic floor relaxation). Medications commonly used during and after surgery can cause urinary retention including atropine, glycopyrrolate, bupivacaine, etc. The addition of opioids for post-operative pain can further exacerbate retention.
As stated above, urinary retention is rare in women and much more common in men due to benign prostatic hyperplasia (BPH). There are an estimated 3 cases per 100000 women every year, and the female to male ratio is 1 to 13. Compare this with men where about one-third over the age of 80 will have acute urinary retention.
Voluntary urination requires coordination between muscles in the pelvic floor, bladder, and urethra and the nerves that innervate them. Any disruption along the pathway can cause urinary retention. Even if this pathway is coordinating and working properly, mechanical obstruction along this pathway will also cause urinary retention. Obstruction can result from the urethral channel undergoing narrowing or possessing increased muscle tone. Neurological impairment can be due to incomplete relaxation of the urinary sphincter, inefficient detrusor muscle contraction, spinal cord infarction/demyelination, epidural abscess, epidural metastasis, Guillain-Barre, neuropathy, stroke, or trauma to the spinal cord. Trauma to the lower GU tract such as the pelvis or urethra can also cause obstruction. Obstruction in women may result from constipation, pelvic organ prolapse, pelvic masses, or kidney stones. A urinary tract infection can cause swelling or inflammation of the urethra; this can cause compression of the urethra and lead to urinary retention.
History and physical should focus on any history of urinary retention and symptoms involving the lower genitourinary (GU) tract such as discomfort with urination, hematuria, urethral discharge, foul smell to the urine, or lower abdominal pain. The patient should also be questioned about previous trauma, surgeries, or radiation to the pelvic and GU area. To evaluate possible other causes in certain patient populations, whether the patient has a history of back pain, fever, IV drug use, or other neurological symptoms could point to serious causes of the urinary retention. All medications including OTC, prescription, and herbal should be reviewed to determine whether side effects of these could be causing the urinary retention. Physical exam should include at least lower abdominal palpation, rectal exam, pelvic exam, and neurological exam. On palpation of the lower abdomen, the patient may have discomfort or the bladder may be palpable. On rectal exam, you want to check for masses, fecal impaction, perineal sensation, and sphincter tone. The pelvic exam could reveal tumors, urethral diverticulum, cystocele, rectocele, etc. as the cause of retention. A neurological exam could also reveal other deficits that may pinpoint where the lesion may be.
A urinalysis and culture is necessary for all patients with urinary retention. This urine may have to be obtained via catheterization if the patient is unable to voluntarily void. Other lab work, imaging, and tests should be ordered based on the provider's suspicion for the cause of retention, history, and physical exam findings. The diagnosis of urinary retention is commonly made via obtaining a post void residual. If the patient can void on her own, a bladder scan is utilized after the patient urinates to evaluate the amount of urine still in the bladder. More than 300 mL of urine in the bladder after voiding suggests urinary retention. If the patient is unable to urinate, catheter placement may necessary. If more than 400 mL of urine passes after catheterization in the first 15 minutes, this suggests urinary retention and the catheter may remain in place. Between volumes of 200 mL and 400 mL, the catheter may be removed immediately or left in place depending on the clinical scenario. Under 200 mL, the catheter can be removed, and urinary retention is unlikely.
Once the physician has determined the diagnosis of urinary retention, they should perform bladder decompression via catheterization. In patients who are not able to void at all specialists prefer urinary catheterization, but one can also perform suprapubic catheterization if there are contraindications to urethral catheterization. Contraindications to urethral catheterization include recent urological surgery. If the patient requires suprapubic catheterization, someone trained in the procedure should perform the procedure. Whether a urinary catheter remains in place is determined by the clinical scenario. If the physician determines the cause of retention to resolve relatively quickly, the patient can be taught how to straight cath themselves intermittently and discharged home. If the patient cannot straight cath themselves for any reason, or the cause is thought to be ongoing, the catheter should remain in place. Most patients with urinary retention are manageable as an outpatient. Indications for admission include sepsis caused by the retention, malignancy as the cause of obstruction, acute myelopathy, or acute renal failure.
Causes are of urinary retention and conditions that may mimic urinary retention include but are not limited to obstruction at any point along the lower GU tract or nerve dysfunction. A blockage may result from pelvic masses, constipation, urethral stone, infection-causing urethral inflammation and stenosis, urethral diverticulum and neurological dysfunction.
Complications of urinary retention include but are not limited to acute kidney injury and urinary tract infection. There are also complications with catheterization, both suprapubic and urethral. Both can result in infection. Urethral catheterization can result in urethral injury during insertion. Suprapubic catheterization can result in trauma to the bladder/colon and overlying skin infection.
Another important complication seen in clinical practice is post-obstructive diuresis. This phenomenon is characterized by excretion of large amounts of salt and water once the obstruction resolves; this may be a normal physiological response to the obstruction, but physicians should keep a close eye on patients as some continue to excrete large amounts of urine and are at risk for dehydration and metabolic abnormalities.
Further testing and evaluation depend on physical exam findings such as gynecology for vaginal defects, neurosurgery for spinal trauma, urology for urodynamic studies.
Urinary retention is the inability to pass urine and can be acute or chronic. Although uncommon in women when compared to men, sill this can lead to significant issues like not urinating at all when the problem is not recognized early. Patients should speak with their doctors if they have any issues urinating, dribbling of urine intermittently, foul smell of urine. Patients should also be aware of medications which can cause urinary retention.
Diagnosis and treatment of urinary retention requires an interprofessional team effort. Primary care physicians, emergency department physicians, and hospitalists should be able to recognize the early signs and symptoms of urinary retention. Nurses should monitor the urine output in hospitalized patients and report to physicians if they notice a decrease or complete absence of urine output. Consultation with urologist might be warranted in advanced cases. Pharmacists also have a role in recognizing the medications which can cause urinary retention. Unfortunately, despite optimal treatment, recurrence of urinary retention is common. The best outcomes are achieved with an interprofessional approach. [Level 5]
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